Ready to start on the road to recovery?

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Name

Email Address

History

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? YesNo

If Yes, and you would like to share more about those services, please do so here:

Are you currently taking any prescription medication?YesNo

If yes, please list and provide reason:

Have you ever been prescribed psychiatric medication?YesNo

If yes, please list and provide reason and dates:

Have you ever suffered any traumatic physical injury, e.g. accidents or significant injuries from sport or recreational activities? YesNo

If yes, please describe briefly with dates:

Have you ever suffered any emotional trauma that you believe I should know about, even if you’re not willing or ready to discuss it?YesNo

If yes, please provide words or phrases that we can use to refer to them. They could be dates that you would recognize, short descriptions or anything that would bring it to mind if I mentioned it. Also, note if you are not willing or ready to discuss it.

Please describe briefly what brings you to therapy:

General and Mental Health Information

Please list any specific health problems you are currently experiencing:

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?

What types of exercise do you participate in?

Please list any difficulties you experience with your appetite or eating problems:

Are you currently experiencing overwhelming sadness, grief or depression? YesNo

If yes, for approximately how long?

Are you currently experiencing anxiety, panics attacks or have any phobias? YesNo

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain?YesNo

If yes, when did you begin experiencing this?

Do you drink alcohol more than once a week?YesNo

How often do you engage in recreational drug use?

Are you in recovery? If so, for how long?

Are you currently in a romantic relationship?YesNo

If yes, for how long?

Why did you choose that?

What significant life changes or stressful events have you experienced recently?

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

Alcohol/Substance Abuse YesNo

Relationship

AnxietyYesNo

Relationship

DepressionYesNo

Relationship

Domestic ViolenceYesNo

Relationship

Eating DisordersYesNo

Relationship

ObesityYesNo

Relationship

Obsessive Compulsive BehaviorYesNo

Relationship

SchizophreniaYesNo

Relationship

Suicide AttemptsYesNo

Relationship

Alcohol/Substance Abuse YesNo

Relationship

Times

Additional Information

Are you currently employed?YesNo

If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current work?

Do you consider yourself to be spiritual or religious?YesNo

If yes, describe your faith or belief:

What do you consider to be some of your strengths?

What do you consider to be some of your weaknesses?

What would you like to accomplish from your time in therapy?

Is there anything else you think I should know before we begin therapy?